Unapproved abbreviations????

[jessi1106, BSN, RN]

I am a new nurse and work in a large teaching hospital. During central nursing orientation we were given a list of abbreviations like "QD" are now unacceptable. (Rather the doc must write "every day", etc.)

Many, many docs are still using unapproved abbreviations in their orders. When I call to ask for a rewrite, the docs are not pleased....most of my peer nursing staff do not call.

I am breaking hospital policy if I don't clarify.....it really is not considered a valid order if written QD.

I am a new nurse at a new job and I don't really know what to do.

Do I keep calling for clarification? (I hardly have time to provide all pt care and documentaion as it is, and no one seems to appreciate my clarifying/following policy).

Do most hospitals have unapproved abbreviations now?? (oh how I hope we go to an all computerized system soon, lol)

[TazziRN, RN]

All hospitals that are JCAHO-accredited have this list. It was developed because of mistakes: MS could mean morphine sulfate or mag sulfate. the "u" for units could be mistaken for a zero when written sloppily.

This may make you unpopular amongst the medical staff, but I would keep doing what you're doing. Rather than calling them, however, you might try leaving notes for them about it to see on their next rounds unless it's so unclear you're not sure what they really wrote.

[Jabramac]

For a while there we were to call MD's anytime there was an unapproved abbreviation to clarify. However, after some time administration told us that JACHO backed down on having unapproved abreviations on the chart because "it is not nursings responsibility to change culture of the physicians." At least that is what we were told. We now just eave notes on the chart for the next time they round to correct it.

[Dolce, RN]

This is why computerized order entry is such a huge help! No more being "chart police" and the enforcer of hospital policy. Unfortunately, I have worked with a few docs who are so stubborn that you could call them 100 times to inform them that QD is not acceptable and they would still not change. Unless the order in illegible I would just leave a note on the chart to please rewrite orders. At least then you have done your part.